Much of my time is spent either helping practitioners be proactive in developing an internal audit prevention program or providing defense-related activities in audit proceedings. The former often helps avoid the latter.

Part of any business strategy is based upon a simple SWOT analysis—strengths, weaknesses, opportunities and threats. Having an internal process for coding and medical record compliance to which we can apply a SWOT analysis is also fundamental for creating a strong practice.

Investigate, review, analyze and report exactly where you and your office team stand. You may even find that you are doing many things well—a bonus.

Collect and Reflect

Often, there are three main issues in an audit for a practice. A lack of medical necessity noted in record for the type and level of visit or for special ophthalmic procedures and surgical services. There could be improper coding of office visits based on poor record keeping of time or medical decision-making (MDM). Sometimes, there is improper use of modifiers -25 and -59 by when clinical use is not met or the definition of the modifier is not met. 

To collect information, start with a random sample. Maybe pull every fifth record from your medical records until you have a sample of 20 or 25. From that cohort, pull actual claims as well as associated financial records. Also make sure to have the current AMA CPT book, ICD-10 library, current policies for your zip code from your contracted medical carriers, CMS LCDs, etc. 

Once you’ve collected everything, evaluate the following areas:

a. Was the patient status (new or established) calculated properly?

b. Did you properly determine the chief complaint that brought the patient in on that specific day?

c. If using E&M codes, did you perform a medically appropriate history and examination commensurate with the patient’s presentation?

d. Did you properly document and sum total time if using time as the E&M code criterion?

e. Did you properly document your MDM if using that as the E&M code criterion?

f. Was the type (920XX or 992XX) and level of the exam appropriate for the specific patient presentation?

g. Did you properly determine all diagnoses specific to your examination and map them properly to the correct CPT code?

h. Did you properly determine and record medical necessity for each and every special ophthalmic test ordered and performed?

i. Did you properly create an interpretation & report (I&R) for each test performed?

j. Did you research the CCI edits to make sure that you can actually perform the tests indicated on the same day prior to doing the tests?

1. If using a modifier, do you meet the definition?

k. If you are having the patient back for a surgical procedure, did you review the surgical preamble defining a surgical package and what is included in that? 

l. If using a modifier, did you read all documentation necessary to determine if your clinical application has met the definition of using this modifier?

m. Did you complete an operative report for every surgical procedure performed? 

Moving Forward

A SWOT analysis of this information  is now easy. What were your identified strengths? Did you consistently have a chief complaint listed on every visit? Did you do a great job in completing an I&R for every special ophthalmic test? What were your identified weaknesses? Perhaps you could have done a better job in cross-referencing the CCI edits prior to testing or recording time in your medical record. 

Properly identifying these two sides provides the foundation for your opportunities. What can you correct? Who is responsible for monitoring these changes? By going through this exercise, you can reduce the threat of criminal, civil and financial exposure the practice may have due to improper coding and compliance practices.

Building a successful practice is not just about making money through proper clinical care and appropriate coding and billing; it is also about keeping the money you have made.

Send your coding questions to [email protected].

Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.